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Turkey: An Overview on National Drug Use, Treatment Design, and the Characteristics of
Patients Utilizing Treatment
Katherine Waye
University at Albany, School of Public Health
Thesis Advisor: Dr. Arash Alaei
The Global Institute for Health and Human Rights
May 2016
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Acknowledgements
My greatest thanks go to my constant mentors at the Global Institute for Health and
Human Rights, Dr. Arash Alaei and Dr. Kamiar Alaei. Thank you for teaching me so many
important lessons and providing me with a meaningful learning experience during my time at the
GIHHR and UAlbany. Further thanks go to Dr. Melissa Tracy who provided us with the
epidemiological dissemination of the data from Turkey. Lastly, thank you to my friends and
family for supporting me through my undergraduate education.
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Abstract
Existing research on the patterns and risk factors of drug use and how they vary by age
and location in Turkey is limited. The paper will examine the drug treatment options within
Turkey as well as the socio-demographic characteristics, behaviors, treatment history, and
identified correlates of lifetime and current injection drug use of Turkish citizens who were
admitted to inpatient substance use treatment at public and private facilities in Turkey during
2012 and 2013. Of the 11,247 patients at the 22 public treatment centers in 2012-2013, a
majority were male, lived with family, were unemployed, and had an average age of 27 years.
Significant predictors of injection drug use included being homeless, having higher education,
heroin as a preferred drug, having a longer duration of drug use, and prior drug treatment. With
this information, greater prevention and intervention efforts can be made to reduce the transition
to drug use among the youth population as well as improve access to a variety of tailored
treatment options.
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Introduction
Substance use disorder is a complex yet treatable disease that seldom exists as an
independent entity and frequently occurs alongside a number of comorbidities like HIV/AIDS,
HCV, and other mental disorders. Turkey currently faces the difficulty of instituting an effective
nation-wide program that combats addiction due to the range of physical, psychological, and
social issues substance use embodies. The Turkish Ministry of Health provides national
treatment for drug use through 22 existing governmentally funded Research, Treatment and
Training Centers for Alcohol and Substance Addiction (AMATEM centers) that are located in 13
of the 81 provinces of Turkey (TUBIM, 2012). With so few facilities, inconsistencies and
limitations in obtaining addiction treatment are widespread. Moreover, the extensive ties
between addiction, society, and environment are often not reflected in current treatment models.
Alongside the difficulty of instituting effective and comprehensive drug treatment
options, Turkey is facing an increased number of individuals seeking treatment for heroin use for
the first time, one of the most addictive illicit drugs, with an almost 45 percent increase from
2004 to 2009 (Barrio et al., 2013). Geographically speaking (see Figure 1), Turkey is located
within a transit route that makes it extremely conducive to varied markets, especially so for the
trade and utilization of narcotics like that of heroin (Akgoz et al., 2007). The drug trafficking
route originates in Afghanistan, a country that contributed to 93% of world’s opium supply in
2007, and extends to Europe (Todd et al., 2007; WHO, 2008) Due to this, Turkey acts as a
middleman for the transit of drugs, with its vicinity to Afghanistan and borders next to the Black
Sea and the Caspian Sea port – both maritime locations increasingly utilized for the transport of
illegal drugs (Zaitseva, 2002). Although a susceptible location to drug trafficking routes, Turkey
is also a culturally unique country. Due to its geographical placement, the nation has
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sociocultural ties to both Middle Eastern and European countries and values. Turkey is a
secularized country, however still faces regional differences between local, traditional beliefs
and Westernized practices. Such variability within population demographics, culture,
urbanization, wealth, and income inequality can contribute to variant risk for drug use (Galea et
al., 2003; Baumann et al., 2007). Even with such distinct country characteristics, current research
on the frequency, trends and associated risk factors of drug use within Turkey are far and few in
between—usually focusing in single cities or provinces (Akgoz et al., 2007; Barrio et al., 2013).
Studies that have been conducted in Turkey report an increase in polysubstance use, a
higher prevalence of cannabis use, and a reduction in the mean age at first heroin use (Akgoz et
al., 2007; Demirci et al., 2014). Such growing trends are notable to recognize as they indicate
that drug use is becoming more common within Turkey and seen amongst younger cohorts.
The two goals of this thesis are to: 1) Conduct a comprehensive overview and analysis of
Turkey’s current drug treatment offerings and 2) Describe and identify the characteristics of
inpatients admitted to public and private facilities in Turkey from 2012 to 2013. Analyzing
Turkey’s treatment set up and organization as well as data collected on individuals admitted to
inpatient treatment are critical first steps in further understanding a vulnerable subset of Turkey’s
population (people who use drugs), creating improved patient care models, and identifying key
areas for prevention strategies.
Drug Treatment in Turkey
AMATEM centers provide both outpatient and inpatient options; however outpatient
services are used at much higher frequencies than inpatient options (TUBIM, 2012). Turkey’s
2012 Annual National Drug Report (TUBIM) states that approximately 150,000 patients seek
outpatient treatment within the 22 AMATEMs (TUBIM, 2012). According to our data collection
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in 2012 to 2013, 11,247 utilized inpatient treatment and 663 utilized private centers. 98% of
Turkish citizens are covered by its general health insurance, which in accordance with Turkey’s
Law on Social Security and General Health Insurance, covers all services and costs provided at
AMATEMs (TUBIM, 2012). Only 1.5% of Turkish citizens will utilize additional supplementary
private insurance that assists in covering costs at private facilities (Drechsler & Jutting, 2007;
Colombo & Tapay, 2004). Usually, PWUD that do seek private treatment facilities do so for the
desire of anonymity and VIP services. However, such private treatment includes additional fees
that either are covered by private insurance or paid out of pocket. Currently, the private sector for
drug use treatment in Turkey has been growing because drug users are fearful of disclosing their
status at the public AMATEMs. Since patients are utilizing the general health insurance when
accessing AMATEMs, doctors must report all cases, including the patient’s name, to a national
registry (Ay & Karabey, 2006). However, private clinics must report their caseload, but can
preserve the anonymity of their patients and are not legally required to include patient names (Ay
& Karabey, 2006). Further, when admitted to an AMATEM center, the patient name and file can
be accessed by any national body, including those that will determine whether a patient is able to
pursue certain professions. Such policies can lead to stigmatization, fear of disclosure/lack of
confidentiality, and issues with finding jobs.
Treatment procedures and detoxification therapy are vital to successful programs and the
overall relapse of the clinic’s patients. Opioid assisted therapy is a growing global trend in the
past years for opiate drugs, which are naturally derived from opium. Opioids, the most common
being buprenorphine and methadone, are synthetically derived from opiates (Whelan & Remski,
2012). Opioids are considered agonists—mimicking the biological effects of opiates, like the
rush of endorphin and encephalin, yet at a lesser level than opiates (Whelan & Remski, 2012).
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The standard medication-assisted treatment (MAT) approach in AMATEM and private clinics is
solely through the application of Suboxone, a buprenorphine/naloxone combination oral
medication (EMCDDA, 2014). Buprenorphine is a partial opioid agonist that has been lauded by
many scientists for a lower potential for abuse and lower overdose risk than that of the
methadone treatment option (Whelan & Remski, 2012). Naloxone is an opioid antagonist that
partially blocks the addictive effects of opiates (NIDA, 2014). According to the World Health
Organization (WHO) the most successful approaches to drug addiction treatment is through
methadone maintenance and buprenorphine substitution therapies, yet methadone approaches are
considered even more effective. Methadone is currently not offered in Turkey due to legal and
policy considerations where methadone is considered a full opioid agonist (whereas
buprenorphine is a partial agonist). Methadone is reported as too close in bodily response to
PWUD’s original substance of addiction—an opiate—thus essentially replacing a substance with
another substance. Methadone and buprenorphine, which were historically used for pain
management, mimic the patient’s psychoactive substance of choice (i.e. opium or heroin) and are
administered by healthcare workers during replacement treatment (WHO, 2008). After a series of
time, the patient is slowly weaned off the methadone and/or buprenorphine treatment.
Alongside the medical substitution detoxification process, other psychological
interventions are applied at Turkish treatment facilities, some of which include: motivational
interviewing, cognitive behavioral therapy, and group therapy. However, even with these public
and private facilities, according to TUBIM, nearly half of the individuals admitted to
AMATEMs return for additional treatment—a trend that must be comprehensively identified and
understood so as to lower rate of relapse (TUBIM, 2012).
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HIV/AIDS and HCV in Turkey
At the end of 2013, there were approximately 1,350 reported HIV cases and
approximately 100 reported AIDS cases in Turkey (Gorkem, 2015). There is an exponential
upward trend in incidence of HIV/AIDS cases in the last decade (as seen by Figure 2). Turkey
has one of the lowest occurrences of the virus, however the fact remains that two-thirds of the
infections occurred after 2003—thus illustrating an aggressive growth in HIV diagnoses. In
2013, the Turkish Ministry of Health reported HIV rates amongst intravenous drug users at 1%
(See Figure 3). Further, in 2013, 51% of those diagnosed with HIV had an “unknown” route of
transmission, thus heralding the need for greater systematic reporting of HIV cases. Patients may
also fear stigmatization when reporting their true route of transmission or have a lack thereof of
education on how HIV is transmitted (Gorkem, 2015). Such a large percentage must be
addressed and decreased, since Turkey’s HIV positive population is predominantly young.
Approximately 25% of the HIV positive population is aged 25 to 35 years old (Duygu, 2016).
With such a young age of occurrence, HIV/AIDS will have to be managed by Turkey’s
healthcare system well into the future.
Another common related risk with injecting drug use is the prevalence of the Hepatitis C
Virus (HCV). HCV can be transmitted through blood transfusion of unscreened donors, injection
drug use, unsafe therapeutic injections, and other healthcare procedures. However, the majority
of recent global HCV reports occur primarily form injection drug use (Shepard et al., 2005).
Treatment options for HCV infection are available, however service uptake is low, particularly
among people who inject drugs (PWID) -- leading to a substantial burden of HCV-related
morbidity and mortality in PWID populations, including liver failure and related complications
(Bruggmann et al., 2015). Besides the immediate burden of HCV infection to the patient, HCV is
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transmitted ten times more efficiently than HIV when intravenous practices are present
(Strathdee et al., 2002) Therefore, high HCV rates are important indicators that may also
foreshadow future HIV epidemics given the similarity of the risky behaviors and injection
practices of PWID that spread both infections (Todd et al., 2007; Kuo et al., 2006).
According to TUBIM, of the 866 injecting drug users receiving inpatient care in 2011,
48.6%, or 351 of the 722, were tested positive for Hepatitis C (TUBIM, 2012). As age increases,
the risk for contracting HCV grows. HCV positivity was at 65.15% for people who were
injecting drugs for more than 10 years (TUBIM, 2012). With heightened and longer drug use, the
higher the chance of contracting risk related diseases like HCV or HIV/AIDS. The prolific
growth of HIV/AIDS in such a short time span and the high prevalence of HCV coincide with
the need for greater coordinated steps in preventing and treating drug use and related risks.
Treatment programs for substance use need to focus upon comprehensive, community-based care
that caters not only directly to substance use, but also related risks that arise with addiction.
Objectives of the Study
With this distinct combination of unique characteristics and demographics within Turkey,
the objectives of this study are to describe the characteristics of individuals admitted to both
public and private facilities for inpatient drug treatment in Turkey from 2012 to 2013, and to
identify the correlates of PWID both in their lifetime and in the past month. Other aims include
identifying the correlates of needle sharing and HCV infection so as to better understand the
risky practices among PWID in Turkey and their contribution to the spread of HCV and HIV.
Comprehensively analyzing and disseminating data collected on individuals admitted for
treatment and correlates of HCV and HIV among people who use drugs (PWUD) in Turkey is a
critical first step in understanding what can be done to better assist PWUD, create tiered
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preventative measures for PWUD and PWID, halting the transmission of HCV and HIV, and
identifying holistic and need-specific models to treatment.
Methods and Study Participants
Turkish citizens that were admitted to inpatient AMATEM centers or at private clinics in
Turkey in 2012 or 2013 were part of the statistical dissemination. AMATEM centers are public
and are predominantly located in major cities of Turkey. All services at public facilities, as
aforementioned, are provided free of cost by Turkey’s Social Security Institution (TUBIM,
2012). TUBIM reports that approximately 150,000 patients utilized outpatient options at the 22
public centers; therefore inpatients at AMATEMs are a distinct minority of all individuals
seeking treatment in Turkey.
Information on the inpatients (socio-demographic characteristics and drug use behaviors)
were obtained by clinic staff through a modified version of the Treatment Demand Indicator 2.0,
which is created and supported by the European Monitoring Center for Drugs and Drug
Addiction (EMCDDA, 2000). Buprenorphine and methadone treatments are not available in
Turkey and such questions were not included in the questionnaire. Socio-demographic
characteristics included gender, age, number of years of education, living situation (alone, with
family, with friends, in a shelter, or homeless), and employment status (regular job, temporal
employee, unemployed, or other).
History of drug use and current drug using behaviors were also obtained via the
questionnaire, including age at first use, frequency of use in the past month, and preferred route
of administration (injection, smoking, snorting, and eating or drinking) for up to three drugs,
including the primary substance of choice. Drug types included heroin, other opioids (e.g.,
meperidine and morphine), cocaine, cannabis, synthetic cannabis (e.g., bonzai), club drugs (e.g.,
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ecstasy, ketamine, methamphetamine), prescription medications (e.g., alprazolam, diazepam,
zolpidem), and inhalants (e.g., glue, paint thinner). From this information, we identified
individuals who had used multiple types of drugs in the past month. We also calculated each
individual’s duration of drug use based on the minimum age of first use of any reported
substance. Individuals were also asked if they had ever injected a drug, and whether they had
injected in the past 30 days. Further, information was obtained about whether the individual had
received inpatient drug treatment in any treatment center previously.
Individuals who reported ever having injected a drug were questioned about their age at
first injection, whether they had ever shared a syringe, and whether they had injected and shared
a syringe in the past 30 days. Finally, individuals were tested for Hepatitis B virus (HBV),
Hepatitis C virus (HCV), and Human Immunodeficiency Virus (HIV).
Turkey is divided into seven geographic regions, as depicted in Figure 4. The public and
private treatment centers were grouped by location into these seven locations: Marmara
(including Istanbul, Bursa, and Edirne), Aegean (including Izmir, Manisa, and Denizli),
Mediterranean (including Antalya, Adana, and Mersin), Central Anatolia (including Ankara,
Konya, and Kayseri), Southeast Anatolia (including Gaziantep and Diyarbakir), Black Sea
Region (including Samsun), and East Anatolia (including Elazig). Istanbul, Izmir, and Ankara
have multiple treatment centers. Figure 4 further labels these general locations of the private and
AMATEM clinics as per the red dots.
With the assistance of epidemiologists, analyses on the survey data were conducted using
chi-square tests for categorical variable and ANOVA for continuous variables. Multiple logistic
regression models were estimated that predicted lifetime and current injection, including
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predictors that were at least marginally significant, with a p-value less than .10 in bivariable
analyses.
Characteristics of People Who Use Drugs
Using data from public and private facilities, we identified key characteristics of
substance users in Turkey who sought inpatient treatment, including differences in drug-using
behaviors by age. As seen in Table 1, within AMATEM centers, a majority were male (94.3%),
had been living with family (94.7%), and were unemployed (64.4%); the average age of
individuals was 26.6 years old. Heroin was the most commonly reported drug of choice (75.4%),
followed by cannabis (13.2%). In contrast, private clinic patient characteristics included a higher
proportion of patients that were female, aged 11-17 years old, had a regular job, used cannabis or
synthetic cannabis as their primary drug, reported snorting as their primary route of
administration, and had previously received drug treatment (Table 1).
Characteristics of substance users admitted for inpatient drug treatment in this study were
similar to those observed in other countries. In studies done in South Africa, Malaysia, China,
and Egypt, most users were also male, unemployed, homeless, utilized heroin as the drug of
choice, and were between the age of 20 and 30 (Hasan et al., 2009; Saban et al., 2014; WHO,
2009).
HCV, HBV and HIV
HCV was reported in 47.1% of the patients who ever injected drugs and 51.9% of those
that injected in the past 30 days (Table 6). This high prevalence of HCV outreaches reports of
HCV seen in Afghanistan (36.6%) and New York City (42-52%) (Todd et al., 2007; Des Jarlais
et al., 2003). However, in Pakistan and Iran, HCV rates are about 30% higher with reports at
88% and 80% (Kheirandish et al., 2009; Kuo et al., 2006). These rates are notable since Pakistan
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and Iran are border nations to Afghanistan—where some of the largest opioid production occurs
in the drug market (WHO, 2008). As border nations, these countries are key in the selling and
transporting illegal drugs along this route. Turkey, albeit further from Afghanistan, is part of the
drug route and seems to be showing a mirrored growth of HCV to that of Pakistan and Iran.
HBV, another comorbidity that can be present in injection drug users, was found amongst
the inpatients at 6.2% for those who ever injected drugs and at 5.9% for those who injected in the
past 30 days. These trends follow other prevalence rates found in India (6%), Afghanistan
(6.5%), and New York City (6%) (Todd et al., 2007; Panda et al., 2002).
HIV was quite rare amongst lifetime PWID, with only 15 cases, thus a prevalence of
.34% (Table 6). Regarding comorbidity between infections among lifetime PWID who were
HBV-positive, 50.4% were also HCV-positive. For those who were HIV-positive, 53.3% were
also HCV-positive. As noted earlier, high HCV trends have a tendency to foreshadow future HIV
epidemics. Although HIV is currently at a low reported rate for PWID, it is still ever important to
continue surveillance of this disease since heroin use is continuing its upward trend within
Turkey, which is vastly associated with injection drug use and dirty needle sharing. Further,
harm reduction programs like needle exchange programs are illegal in Turkey, thus access to
sterile needles is extremely difficult. Further research needs to examine whether Turkish PWID
partake in other risky behaviors like unprotected sex that could make them more vulnerable to
contracting HIV in other situations besides injection drug use.
Injection Drug Use and Needle Sharing
Significant predictors of being a PWID included being homeless, being a temporal
employee or unemployed, having higher education, using heroin as a preferred drug, having a
longer duration of drug use, sharing needles, and receiving prior drug treatment (Tables 3 & 4).
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As seen in Table 3, 40.4% of the individuals treated in AMATEMs reported ever
injecting drugs, whereas 33.7% injected in the past 30 days. These trends are consistent with
other studies of PWID who were admitted for substance use treatment; for example, 45% of drug
users in a study conducted in Finland administered their primary dug of choice intravenously
(Onyeka et al., 2012). The characteristics of PWID in our study were similar to other studies
conducted in the Middle East. In Afghanistan and Pakistan a higher proportion of PWID were
male, unemployed, utilized heroin as a drug of choice, and were either homeless or displaced
(Kuo et al., 2007; Sherman et al., 2005; Todd et al., 2009).
Needle sharing is one of the strongest predictors seen in our study for increased
likelihood of HCV (Table 7). When examining a cohort of PWID with clean needles, one report
found that the likelihood of HCV transmission drops to 4% per year amongst those who never
shared needles (Crofts et al., 1999). In contrast, another study of past drug users that were
negative for HCV, rapidly became HCV positive within 1 year of first injection (Hien et al.,
2001). We also found that HCV prevalence increased with greater duration of drug use, with
62.7% of all PWID that have been using for at least 10 years reporting HCV infection.
Further predictors of needle sharing found in our study include being of younger age,
being less educated, and of lower socioeconomic status (Table 6). Being unemployed or not
having the means to afford clean needles has proven to be associated with sharing needles in
several studies (Magura, 1989; Valente et al., 2002). PWID within lower socioeconomic statuses
are forced to determine between buying more drugs or new equipment—due to their addiction,
drugs tend to be the foci of choice (Magura, 1989). Further, in concurrence with our study, age is
highly reflective of increased injection as many reports find needle sharing to be a frequent
practice amongst the youth (Hien et al., 2001). More than half of the PWID that shared needles
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were found to be living with family and a little less than half were found to be living with friends
and sharing needles. One study amongst a cohort of PWID found that 77% of men’s and 80% of
women’s social networks had members that used drugs on a daily basis (Sherman et al., 2001).
In tandem, HCV rates were statistically significant in both living situations for our study. It has
been found that when using drugs with sexual partners or friends, some PWID reported that they
worried their friends would feel insulted if they refused to share needles—thus suggesting that
peer behavior can exacerbate needle sharing and the subsequent contraction of HCV (Magura et
al., 1989).
Women Who Use Drugs
In 2012 and 2013, less than 6% of AMATEM inpatients and less than 10% of inpatients
at private clinics were women (Table 1). These low percentages of women are similar to those
observed in other treatment-seeking populations in post-Soviet countries, Iran, and Malaysia, a
Muslim Asian country, in which 97.6% of PWUD in public treatment were men between 20 and
30 years of age (Otiashvili et al., 2013; WHO, 2009; Dolan et al., 2011). It is unclear whether the
small proportion of women utilizing treatment in Turkey reflects a lower frequency of drug use
among women or reluctance among women to seek treatment due to stigma or other barriers that
hinder access to treatment (TUBIM, 2012). AMATEM doctors must report all patients, including
the patient’s name, to a national registry; this lack of anonymity at public centers may be an
important barrier to treatment access, particularly among Muslim women, who may avoid
seeking help for drug use due to fear of negative community consequences (Ay & Karabey,
2006; Cifti et al., 2012).
To be noted, a higher proportion of women were utilizing private clinic patients (6% vs.
10%), which may reflect a general increase in private sector drug use treatment in Turkey
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because PWUD, especially females, are fearful of disclosing their status at public treatment
centers. Indeed, in a study in multiple Middle Eastern countries, women who use drugs
(WWUD) reported stigma and discrimination in the forms of social distancing, rejection,
humiliation and denial of rights as frequent obstacles to treatment services (MENAHRA, 2013).
By contrast, in the European Union and United States, where female drug users are less
stigmatized, women comprise 20-40% of those in treatment (Otiashvili et al., 2013). Even in
China, a country with some of the highest reported heroin use, 17% of inpatients were female,
with this higher rate most likely attributed to the gender specific treatment options that China
offers (WHO, 2009).
Additionally, in public treatment centers, there is a requirement that those who receive
drug services must also receive HIV tests, while this is not the same in private clinics. Due to the
potential for stigmatization based on HIV status, this may make private centers even more
attractive to female drug users. For example, in 2002, home HIV tests were becoming a
widespread mode for HIV testing amongst women in Turkey (“Woman Attention”, 2002).
Married women often stated within the article that they feared being labeled as a “woman who
cheats on her husband” if they were to go to a lab or hospital to receive HIV testing services—
illustrating the types of stigmatization issues in Turkey that bar women from receiving such
services (“Woman Attention”, 2002). Upon patient stigmatization, the patient can be more likely
to suffer from self-esteem issues and less likely to engage in the treatment procedure, further
perpetuating the many risks this vulnerable population faces (Vanable et al., 2006).
Age Differences and Youth Drug Use
We also noted striking differences in drug-using behaviors between age groups, which
highlights the need for intervention and prevention efforts targeted towards adolescents in
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Turkey. As seen in Table 2, compared to the older individuals in treatment, there were a higher
proportion of females in the youngest age group (18.8%), as well as individuals living in a
shelter (8.6%) and reporting being unemployed (75.6%).
Nearly 42% of the 11-17 year olds receiving treatment reported utilizing heroin as their
drug of choice (Table 2). In contrast, for adolescents admitted to treatment in the United States in
2011 only, 14.8% aged 12-14 and 16.9% aged 15-17 used heroin as a primary substance of
choice (SAMHSA, 2014). Heroin did not even rank in the top two drugs of choice reported by
15-17 year olds in the US. In further juxtaposition, the misuse of prescription opioids in the US
has been rising since 2002 (Johnston et al., 2009). One study reports that 6.2% of adolescents
aged 12-17 used prescription pain relievers for nonmedical use in the U.S. while in Turkey less
than 0.5% in this age group used prescription medications (SAMHSA, 2015). Similarly, in a
study conducted in Finland, only 2% of those aged 14 or younger used opiates, and only 28% of
those aged 15 to 24 used opiates (Onyeka et al., 2012). Within the 11-17 year age group in our
study, heroin use started at the age of 13 and then increased at each year of age, with nearly 50%
of 17 year olds reporting heroin as their substance of choice. Initiating heroin use at such a young
age increases odds for transitioning to injection, developing risky injection practices, contracting
blood-borne diseases like HIV/AIDS and HCV, and falling victim to drug overdose at earlier
ages (Barrio et al., 2013; Griffin et al., 2003; Onyeka et al., 2012). Alongside this, we noted that
50.1% of the 11-17 year old Turkish inpatients used more than one drug per month (vs. about 2030% in the older age group), most likely reflecting the experimentation stage among youths who
are new to substance use, but nonetheless, increasing the odds of developing chronic
polysubstance use and related harms (Griffin et al., 2003).
Further, the use of cannabis (29.6%) and synthetic cannabis (7.5%) was also particularly
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popular among the youngest Turkish inpatients (Table 2). Bonzai, a type of synthetic cannabis in
Turkey, is becoming a widespread drug of choice with a 19 times increase in bonzai possession
arrests in Turkey from 2011 to 2012 (Çoban, 2014; Atik et al., 2015; Gurdal et al., 2013). Bonzai
is a dangerous drug with debilitating effects on the body that can include increased risk of death
or serious problems in the cardiovascular, neural or digestive systems (Çoban, 2014; Atik et al.,
2015; Gurdal et al., 2013). We observed a nearly six-fold increase in synthetic cannabis usage
from 2012 to 2013 (from 0.9% to 5.2% of inpatients), suggesting that bonzai is continuing its
upward trend due to its promise of a stronger high, affordability, accessibility as it can be
purchased online, and concealment of use since such usage will not create positive toxicological
test results (Atik et al., 2015; Gurdal et al., 2013).
Schooling and Homelessness
In adjusted models of AMATEM inpatients (Table 3), individuals who received
schooling for more than twelve years were more likely to inject than those with lesser education
(adjusted odds ratio of 1.74). 40% of those reporting ever injecting had an education of 12 years
or greater. This finding is converse to other studies that report greater proportions of PWID
among those who have not completed secondary school and did not seek higher education
(Abelson et al., 2006; Chikovani et al., 2011; Latimer et al., 2009; Reyes et al., 2006). PWID
may be influenced by difficulties in finding heroin, as injection allows for a convenient and
efficient means of getting high (Kuo et al., 2007; Todd et al., 2009). However, further research is
needed to understand why injection may be the choice approach for the more educated in
Turkey.
The homeless, albeit a small group comprising about 0.2% of inpatients (Table 1), were
at highest risk for injecting among the sample (odds ratio of 3.68 in AMATEMS), illustrating the
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particular needs of this group. In a study conducted amongst homeless people aged 14 to 26 in
Canada, a relationship was observed between perceived increased drug use and loss of housing
(Cheng et al., 2014). Additionally, research in London among 1,000 homeless individuals
reported that 88% were using at least one drug (Neale, 2008). In a study of homeless adolescents
in Turkey, only 17% reported knowing that substance use could lead to increased risks like
HIV/AIDS, further illustrating that knowledge on the risks of injection is scarce and outreach as
well as health education would be beneficial for homeless populations within Turkey (Baybuga
& Celik, 2004).
Locational Differences
The locations that reported the highest rates of PWID were the Marmara and
Mediterranean regions with 33.4% at Marmara AMATEMs and 59.9% at Mediterranean
AMATEMs vs. 26.5% at Marmara private clinics (Tables 3 & 4). Due to the limited data on
private clinics, we only have locations from the Marmara and Southeast Anatolia regions. 54.2%
of the youngest inpatients, 11-17 year olds, were from the Marmara region, indicating that earlyage prevention efforts may be particularly needed in this area (Table 2). The Mediterranean
region had a high percentage of patients that injected (59.9%), with the highest percentage
among patients of the Adana AMATEM (63.9%). These regions may see higher rates of PWID
because of the Balkan Route, a drug trafficking path for heroin that originates in Afghanistan and
passes through the Marmara and Mediterranean regions (EMCDDA, 2015). In tandem, the most
populated cities in Turkey are located in the Marmara and Mediterranean regions-- Istanbul,
Izmir, Antalya and Mersin. It has also been reported that although the Marmara and
Mediterranean regions are considered some of the wealthiest locations in Turkey due to tourism
and geographic location as port cities, both localities have some of the largest income
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inequalities which can be linked to increased risk for drug use (Galea et al., 2003; Rhodes, 2009;
Pickett & Wilkinson, 2010; Baumann et al., 2007). Further research is needed to understand
whether these regions simply offer the most services and thus cater to higher numbers of
patients, have higher intake due to patients traveling from other regions of Turkey that do not
have treatment facilities, or whether these areas truly have a higher proportion of PWID.
Relapse
Finally, we found that, in 2012 and 2013, about 47% of the public facility sample and
57% of those seen in private clinics reported having received previous inpatient treatment (Table
1). In addition, lifetime and current PWID was more common among those who had received
previous treatment. In one study, patients who revolved in and out of treatment more than three
times had significantly lower treatment improvement and success -- the Turkish drug users with
previous treatment may represent a similarly challenging population (Zhang et al., 2003).
Furthermore, treatment programs offered in Turkey focus primarily on short-term medical
detoxification that lasts two to four weeks through the delivery of Suboxone, but do not offer
long-term maintenance therapy and consistent follow-up (TUBIM, 2012). This further suggests
that treatment in Turkey could be more successful if a combination of short and long-term
offerings were available and also shaped or modified to the characteristics and needs of the
patient.
Limitations
This study had several limitations. First, since the data reflect inpatients admitted to
Turkey’s AMATEM centers and some private centers, the sample may not be representative of
all PWUD and PWID in Turkey. Given the fact that the 22 AMATEMs are located in only 13 of
the 81 provinces, a gap exists in Turkey’s national data for areas that host neither AMATEMs
21
nor private clinics that report to the state (TUBIM, 2012). This could cause limitations in
understanding the demographics and drug-using behaviors of substance users, especially in
northern and eastern areas of Turkey that lack treatment facilities. Observing only individuals in
drug treatment also excludes drug users who are not informed about the public or private clinics,
could not afford such help, or are not coming forward for treatment due to possible stigmas or
cultural biases. In addition, the demographics of the private clinic inpatients were more limited,
with some subgroups like homeless individuals not represented at all. The private clinics’ sample
size was also limited, resulting in very wide confidence intervals. Upon intake, the patients were
asked about their history of drug use, potentially leading to misclassification among those who
may not accurately remember the entirety of their substance use history, like initiation and
duration of drug use. Since this is a cross-sectional study, we cannot infer temporality between
the correlates and initiation of PWID. Finally, we did not collect data on some potential
predictors of injection, like exposure to PWID among friends and family members, which limits
our ability to fully identify all characteristics associated with injection in this sample.
Conclusion
Despite these limitations, this study provides critical insight into the characteristics of
inpatient PWUD in Turkey and the correlates of PWID in this population. The young age at
which Turkish inpatients begin using heroin suggests a strong need for prevention and
intervention efforts focused on the transition to heroin use and injection among youth
populations. Additional efforts are needed to reduce synthetic drug use, like bonzai, among
adolescents. It is critical to note that Turkey is considered a “young population” with the average
age being 29.22 in 2010 (CIDOB, 2011). This further emphasizes the importance of interacting
with younger PWUD so as to slow the growing rates of drug use, especially with that of bonzai
22
and heroin. Possible approaches could include opening more clinics specifically catered towards
the needs of younger patients as well as integrating previously successful drug use prevention
efforts in schools like that of working with at-risk groups, resistance-skills/life-skills training and
social norms campaigns that correct misperceptions about drug use prevalence (Gottfredson &
Wilson, 2003; Griffin et al., 2003).
In addition, further counseling and outreach services are needed for subgroups that are
utilizing inpatient facilities at low rates, including women, people without family, and homeless
individuals. Further qualitative and quantitative research is needed to clarify whether the lack of
representation of these groups among those seeking treatment reflects lower rates of drug use or
underutilization of services. Such research will help identify specific barriers to treatment and
how they can be overcome. Women who use drugs are an understudied subset of this vulnerable
population and face a double stigmatization of being a woman and using drugs within Islamic
countries (Spooner et al., 2015). Research has shown that the implementation of women only
drug treatment facilities would be extremely beneficial for Islamic women who use drugs—
potentially allowing for increased access rates and improved treatment care levels (Prendergast et
al., 2011; Ashley et al, 2003).
Additionally, the regional differences we identified, including high levels of PWID in the
Mediterranean region, suggest that treatment programs could begin to offer counseling, detox
methods geared towards harder drugs, and long-term maintenance therapy to create a more
successful program in lowering addiction to heroin and preventing relapse in these areas.
Finally, as per regulation by Turkey’s Ministry of Health, all substance use treatment facilities,
may they be outpatient or inpatient, must be affiliated and working under local hospital
administration. Due to this regulation, it can be difficult to open and operate clinics in all areas
23
with need, since hospitals may not have the capacity to support treatment facilities and hospitals
do not exist in some areas. Based on this limitation, it would be advisable to consider the
creation of freestanding outpatient treatment facilities so as to increase available services.
Moreover, since AMATEMs are located in only certain areas of Turkey, there is a great need,
especially in the eastern and northern parts of Turkey, to conduct population studies of PWUD so
these locales can be properly represented and their substance use patterns, demographics, and
behaviors can be better understood.
This overview assists in identifying certain populations and types of drug-using behaviors
that are associated with higher risks for injection drug use in Turkey. Such information can be
used to better improve service delivery and develop targeted interventions as well as outreach
efforts for those at greatest risk of injection drug use. It is ever important to identify barriers to
drug addiction treatment and associated qualitative predictors of drug using behaviors so that
currently increasing trends in harmful drug use in Turkey can be reversed and treatment efforts
can be expanded.
24
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FIGURE APPENDIX
FIGURE 1 – MAP OF TURKEY
FIGURE 2- HIV/AIDS 1985 TO 2014
(Gorkem, 2015)
36
FIGURE 3- ROUTE OF TRANSMISSION 2013
(Gorkem, 2015)
FIGURE 4 – CLINICS BY REGION
37
TABLE APPENDIX
TABLE 1
Socio-demographic characteristics, drug use behaviors, and treatment history of individuals receiving inpatient drug treatment in
AMATEMs and private clinics in Turkey, 2012-2013
2012
n = 4586
n
%
Socio-demographic characteristics
Gender
Female
Male
Age
11-17 years
18-29 years
30-39 years
≥ 40 years
Mean age (SD)
Living situation
Alone
With family
With friends
In a shelter
Homeless
Employment
Regular job
Temporal employee
Unemployed
2013
n = 6661
n
%
AMATEMs
Total
n = 11247
n
%
Private clinics
Total
n = 663
n
%
271
4311
6.0
94.0
362
6299
5.4
94.6
637
10610
5.7
94.3
64
599
9.7
90.4
356
2892
979
359
7.8
63.1
21.4
7.8
27.0 (8.4)
472
4508
1279
402
7.1
67.7
19.2
6.0
26.3 (7.5)
828
7400
2258
761
7.4
65.8
20.1
6.8
26.6 (7.9)
87
377
143
56
13.1
56.9
21.6
8.5
26.3 (8.7)
236
4255
20
61
14
5.2
92.8
0.4
1.3
0.3
157
6391
17
86
9
2.4
96.0
0.3
1.3
0.1
393
10646
37
147
23
3.5
94.7
0.3
1.3
0.2
17
642
4
0
0
2.6
96.8
0.6
0.0
0.0
1366
331
2730
29.8
7.2
59.5
1880
0
4507
28.2
0.0
67.7
3246
331
7237
28.9
2.9
64.4
303
0
317
45.7
0.0
47.8
38
Unknown
Education
No formal schooling
1-5 years
6-8 years
9-12 years
> 12 years
Region
Marmara
Aegean
Mediterranean
Central Anatolia
Southeast Anatolia
Black Sea Region
East Anatolia
Drug use behaviors
Preferred drug
Heroin
Other opiates
Cocaine
Cannabis
Synthetic cannabis
Club drugs
Prescription medications
Inhalants
Mean age at first drug use (SD)
Duration of drug use
≤ 2 years
3-5 years
6-9 years
≥ 10 years
159
3.5
274
4.1
433
3.9
43
6.5
111
1276
1992
993
214
2.4
27.8
43.4
21.7
4.7
125
1751
2855
1641
289
1.9
26.3
42.9
24.6
4.3
236
3027
4847
2634
503
2.1
26.9
43.1
23.4
4.5
7
125
295
186
50
1.1
18.9
44.5
28.1
7.5
1716
377
1874
257
29
111
222
37.4
8.2
40.9
5.6
0.6
2.4
4.8
2659
542
2371
697
47
98
247
39.9
8.1
35.6
10.5
0.7
1.5
3.7
4375
919
4245
954
76
209
469
38.9
8.2
37.7
8.5
0.7
1.9
4.2
551
0
0
0
112
0
0
83.1
0.0
0.0
0.0
16.9
0.0
0.0
3413
42
73
676
43
54
61
224
74.4
0.9
1.6
14.7
0.9
1.2
1.3
4.9
19.8 (6.4)
5068
88
57
809
345
54
50
190
76.1
1.3
0.9
12.2
5.2
0.8
0.8
2.9
19.5 (5.7)
8481
130
130
1485
388
108
111
414
75.4
1.2
1.2
13.2
3.5
1.0
1.0
3.7
19.6 (6.0)
418
9
27
122
46
6
4
31
63.1
1.4
4.1
18.4
6.9
0.9
0.6
4.7
19.6 (6.6)
804
1547
1059
1176
17.5
33.7
23.1
25.6
1321
2266
1572
1502
19.8
34.0
23.6
22.6
2125
3813
2631
2678
18.9
33.9
23.4
23.8
161
210
140
152
24.3
31.7
21.1
22.9
39
Frequency of drug use
Every day
2-6 days per week
1 day per week or less
Used multiple drug types in past month
No
Yes
Preferred route of administration
Inject
Smoke
Snort
Eat or Drink
Mean age at first injection (SD)a
Treatment History
Previous drug treatment
No
Yes
a
Among those who ever injected drugs
4456
98
32
97.2
2.1
0.7
6655
5
1
99.9
0.1
0.02
11111
103
33
98.8
0.9
0.3
660
3
0
99.6
0.5
0.0
2993
1593
65.3
34.7
4655
2006
69.9
30.1
7648
3599
68.0
32.0
426
237
64.3
35.8
1706
1121
1635
124
37.2
24.4
35.7
2.7
2088
1292
3136
145
31.4
19.4
47.1
2.2
3794
2413
4771
269
33.7
21.5
42.4
2.4
120
172
361
10
18.1
25.9
54.5
1.5
23.1 (5.8)
2471
2115
53.9
46.1
23.0 (5.5)
3468
3193
52.1
47.9
23.0 (5.6)
5939
5308
52.8
47.2
22.4 (5.4)
285
378
43.0
57.0
40
TABLE 2
Socio-demographic characteristics, drug use behaviors, and treatment history of individuals receiving inpatient drug treatment in
AMATEMs in Turkey in 2012-2013, by age category (n = 11,247)
Age 11-17 years
n = 828
Socio-demographic characteristics
Gender
Female
Male
Living situation
Alone
With family
With friends
In a shelter
Homeless
Employment
Regular job
Temporal employee
Unemployed
Unknown
Education
No formal schooling
1-5 years
6-8 years
9-12 years
> 12 years
Region
Marmara
Age 18-29 years
n = 7400
Age 30-39 years
n = 2258
Age ≥ 40 years
n = 761
n
%
n
%
n
%
n
%
p-valueb
156
672
18.8
81.2
363
7037
4.9
95.1
91
2167
4.0
96.0
27
734
3.6
96.5
<0.001
1
754
2
71
0
0.1
91.1
0.2
8.6
0.0
174
7119
21
73
12
2.4
96.2
0.3
1.0
0.2
120
2120
11
1
6
5.3
93.9
0.5
0.04
0.3
98
653
3
2
5
12.9
85.8
0.4
0.3
0.7
<0.001
84
5
626
113
10.1
0.6
75.6
13.7
2073
216
4860
251
28.0
2.9
65.7
3.4
851
88
1312
7
37.7
3.9
58.1
0.3
238
22
439
62
31.3
2.9
57.7
8.2
<0.001
8
151
552
114
3
1.0
18.2
66.7
13.8
0.4
154
1630
3404
1895
317
2.1
22.0
46.0
25.6
4.3
48
911
679
490
130
2.1
40.4
30.1
21.7
5.8
26
335
212
135
53
3.4
44.0
27.9
17.7
7.0
<0.001
449
54.2
2754
37.2
881
39.0
291
38.2
<0.001
41
Aegean
Mediterranean
Central Anatolia
Southeast Anatolia
Black Sea Region
East Anatolia
Drug use behaviors
Preferred drug
Heroin
Other opiates
Cocaine
Cannabis
Synthetic cannabis
Club drugs
Prescription medications
Inhalants
Mean age at first drug use (SD)
Duration of drug use
≤ 2 years
3-5 years
6-9 years
≥ 10 years
Frequency of drug use
Every day
2-6 days per week
1 day per week or less
Used multiple drug types in past month
No
Yes
Preferred route of administration
Inject
83
102
113
74
5
2
10.0
12.3
13.7
8.9
0.6
0.2
565
3077
627
2
116
259
7.6
41.6
8.5
0.03
1.6
3.5
190
858
148
0
59
122
8.4
38.0
6.6
0.0
2.6
5.4
346
1
0
245
62
26
1
147
41.8
0.1
0.0
29.6
7.5
3.1
0.1
17.8
13.7 (1.7)
5926
54
55
829
250
61
18
207
80.1
0.7
0.7
11.2
3.4
0.8
0.2
2.8
18.1 (3.7)
1656
50
60
311
70
17
40
54
73.3
2.2
2.7
13.8
3.1
0.8
1.8
2.4
23.5 (5.9)
431
355
40
2
52.1
42.9
4.8
0.2
1442
2948
2025
985
19.5
39.8
27.4
13.3
216
435
490
1117
786
30
12
94.9
3.6
1.5
7341
47
12
99.2
0.6
0.2
413
415
49.9
50.1
5018
2382
87
10.5
2683
81
208
66
0
29
86
10.6
27.3
8.7
0.0
3.8
11.3
553
72.7
25
3.3
15
2.0
100
13.1
6
0.8
4
0.5
52
6.8
6
0.8
29.1 (10.0)
<0.001
9.6
19.3
21.7
49.5
36
75
76
574
4.7
9.9
10.0
75.4
<0.001
2232
19
7
98.9
0.8
0.3
752
7
2
98.8
0.9
0.3
<0.001
67.8
32.2
1614
644
71.5
28.5
603
158
79.2
20.8
<0.001
36.3
831
36.8
193
25.4
<0.001
<0.001
42
Smoke
Snort
Eat or Drink
343
371
27
41.4
44.8
3.3
1448
3164
105
19.6
42.8
1.4
472
878
77
20.9
38.9
3.4
Mean age at first injection (SD)a
15.2 (1.4)
21.2 (3.3)
27.2 (5.0)
Treatment History
Previous drug treatment
No
626
75.6
4096
55.4
968
42.9
Yes
202
24.4
3304
44.7
1290
57.1
a
Among those who ever injected drugs
b
p-value from Chi-square test for categorical variables and ANOVA for continuous variables
150
358
60
249
512
19.7
47.0
7.9
33.0 (8.7)
<0.001
32.7
67.3
<0.001
43
TABLE 3
Correlates of lifetime and current injection drug use among individuals receiving inpatient drug treatment in AMATEMs in Turkey in
2012-2013 (n = 11,247)
Lifetime injection drug use
Total
Socio-demographic
characteristics
Gender
Female
Male
Age
11-17 years
18-29 years
30-39 years
≥ 40 years
Living situation
Alone
With family
With friends
In a shelter
Homeless
Employment
Regular job
Temporal employee
Unemployed
n ever % ever
injected injected
4545
40.4
Adjusted OR
(95% CI)
p-value
Current injection drug use
n
%
injected injected
in past in past
30 days 30 days
3794
33.7
Adjusted OR
(95% CI)
p-value
197
4348
30.9
41.0
<0.001
1.00
1.04
(ref)
(0.84 - 1.29)
141
3653
22.1
34.4
<0.001
1.00
1.25
(ref)
(1.00 - 1.56)
120
3151
1008
266
14.5
42.6
44.6
35.0
<0.001
1.00
1.27
1.26
0.66
(ref)
(1.00 - 1.61)
(0.96 - 1.64)
(0.48 - 0.90)
87
2683
831
193
10.5
36.3
36.8
25.4
<0.001
1.00
1.34
1.19
0.57
(ref)
(1.03 - 1.74)
(0.89 - 1.59)
(0.40 - 0.80)
167
4307
18
40
13
42.5
40.5
48.7
27.2
56.5
0.005
1.00
0.78
1.53
1.46
3.68
(ref)
(0.60 - 1.01)
(0.68 - 3.41)
(0.83 - 2.58)
(1.14 - 11.89)
144
3595
16
27
12
36.6
33.8
43.2
18.4
52.2
<0.001
1.00
0.72
1.70
1.02
3.84
(ref)
(0.56 - 0.93)
(0.77 - 3.78)
(0.56 - 1.86)
(1.23 - 12.00)
1200
163
3067
37.0
49.2
42.4
<0.001
1.00
1.31
1.18
(ref)
(1.00 - 1.71)
(1.07 - 1.31)
996
147
2572
30.7
44.4
35.5
<0.001
1.00
1.41
1.16
(ref)
(1.08 - 1.84)
(1.05 - 1.29)
44
Unknown
Education
No formal schooling
1-5 years
6-8 years
9-12 years
> 12 years
Region
Marmara
Aegean
Mediterranean
Central Anatolia
Southeast Anatolia
Black Sea Region
East Anatolia
Drug use behaviors
Heroin as preferred drug
No
Yes
Duration of drug use
≤ 2 years
3-5 years
6-9 years
≥ 10 years
Used multiple drug types in past
month
No
Yes
Treatment history
Previous drug treatment
115
26.6
1.27
(0.95 - 1.71)
79
18.2
107
1354
1814
1041
229
45.3
44.7
37.4
39.5
45.5
1461
199
2544
248
0
18
75
0.98
(0.71 - 1.34)
<0.001
1.00
1.21
1.07
1.24
1.72
(ref)
(0.89 - 1.65)
(0.78 - 1.45)
(0.90 - 1.69)
(1.19 - 2.48)
95
1148
1502
857
192
40.3
37.9
31.0
32.5
38.2
<0.001
1.00
1.12
0.99
1.14
1.53
(ref)
(0.82 - 1.53)
(0.73 - 1.34)
(0.83 - 1.55)
(1.06 - 2.21)
33.4
21.7
59.9
26.0
0.0
8.6
16.0
<0.001
1.00
0.85
2.04
0.65
n/a
0.63
0.38
(ref)
(0.69 - 1.04)
(1.84 - 2.25)
(0.55 - 0.78)
n/a
(0.36 - 1.12)
(0.29 - 0.50)
1108
158
2268
180
0
16
64
25.3
17.2
53.4
18.9
0.0
7.7
13.7
<0.001
1.00
0.96
2.45
0.66
n/a
0.91
0.52
(ref)
(0.78 - 1.19)
(2.20 - 2.72)
(0.55 - 0.80)
n/a
(0.51 - 1.64)
(0.39 - 0.70)
99
4446
3.6
52.4
<0.001
1.00
22.92
(ref)
(18.51 - 28.37)
73
3721
2.6
43.9
<0.001
1.00
20.59
(ref)
(16.12 - 26.29)
457
1513
1315
1260
21.5
39.7
50.0
47.1
<0.001
1.00
1.89
2.54
3.12
(ref)
(1.65 - 2.17)
(2.18 - 2.95)
(2.64 - 3.69)
384
1237
1137
1036
18.1
32.4
43.2
38.7
<0.001
1.00
1.67
2.34
2.73
(ref)
(1.44 - 1.93)
(2.00 - 2.74)
(2.28 - 3.27)
3080
1465
40.3
40.7
0.662
---
---
2517
1277
32.9
35.5
0.007
1.00
0.86
(ref)
(0.77 - 0.96)
45
No
Yes
1743
2802
29.4
52.8
<0.001
1.00
1.88
(ref)
(1.71 - 2.06)
1447
2347
24.4
44.2
<0.001
1.00
1.73
(ref)
(1.57 - 1.90)
46
TABLE 4
Socio-demographic characteristics, drug use behaviors, and treatment history of injection drug users receiving inpatient drug treatment
in Turkey, 2012-2013
Ever injected drugs
n = 4,694
n
%
Socio-demographic characteristics
Gender
Female
Male
Age
11-17 years
18-29 years
30-39 years
≥ 40 years
Mean age (SD)
Living situation
Alone
With family
With friends
Charity
Homeless
Employment
Regular job
Temporal employee
Unemployed
Unknown
Education
Injected drugs in
past 30 days
n = 3,914
n
%
216
4478
4.6
95.4
155
3759
4.0
96.0
122
3246
1045
281
2.6
69.2
22.3
6.0
27.2 (7.0)
89
2763
858
204
2.3
70.6
21.9
5.2
27.0 (6.6)
173
4448
20
40
13
3.7
94.8
0.4
0.9
0.3
150
3707
18
27
12
3.8
94.7
0.5
0.7
0.3
1285
163
3125
121
27.4
3.5
66.6
2.6
1062
147
2621
84
27.1
3.8
67.0
2.2
47
No formal schooling
1-5 years
6-8 years
9-12 years
> 12 years
Region
Marmara
Aegean
Mediterranean
Central Anatolia
Southeast Anatolia
Black Sea Region
East Anatolia
Location of treatment
Private clinic
Public treatment center (AMATEM)
Drug use behaviors
Drug of choice
Heroin
Other opiates
Other drugsa
Mean age at first drug use (SD)
Duration of drug use
≤ 2 years
3-5 years
6-9 years
≥ 10 years
Used multiple drug types in past month
No
Yes
109
1388
1868
1080
249
2.3
29.6
39.8
23.0
5.3
97
1177
1546
894
200
2.5
30.1
39.5
22.8
5.1
1607
199
2544
248
3
18
75
34.2
4.2
54.2
5.3
0.1
0.4
1.6
1225
158
2268
180
3
16
64
31.3
4.0
58.0
4.6
0.1
0.4
1.6
149
4545
3.2
96.8
120
3794
3.1
96.9
4589
92
13
97.8
2.0
0.3
20.6 (5.1)
3835
72
7
98.0
1.8
0.2
20.6 (5.0)
487
1554
1342
1311
10.4
33.1
28.6
27.9
411
1274
1157
1072
10.5
32.6
29.6
27.4
3181
1513
67.8
32.2
2591
1323
66.2
33.8
48
Mean age at first injection (SD)
23.0 (5.6)
22.9 (5.5)
Ever shared needles
No
1248
26.6
811
20.7
Yes
3446
73.4
3103
79.3
Shared needles in past 30 days
No
2518
53.6
1738
44.4
Yes
2176
46.4
2176
55.6
Treatment history
Previous drug treatment
No
1770
37.7
1468
37.5
Yes
2924
62.3
2446
62.5
a
Other drugs include cannabis, synthetic cannabis, and prescription medications
TABLE 5
Prevalence of HBV, HCV, and HIV infection among injection drug users receiving inpatient drug treatment in Turkey, 2012-2013
n
Ever injected drugs
n = 4,477a
%
(95% CI)
Infection status
HBV-positive
276
6.2
(5.5, 6.9)
HCV-positive
2107
47.1
(45.6, 48.5)
HIV-positive
15
0.34
(0.17, 0.50)
a
Restricted to those with known infection status
Injected drugs in past 30 days
n = 3,718a
n
%
(95% CI)
219
1930
14
5.9
51.9
0.38
(5.1, 6.6)
(50.3, 53.5)
(0.18, 0.57)
49
TABLE 6
Correlates of needle sharing in the past 30 days among current injection drug users receiving inpatient drug treatment in Turkey (n =
3,718)a
Shared needles in past 30 days
%
shared
Unadjusted
Adjusted
n needles
p-value
OR
(95% CI)
OR
(95% CI)
Total
2073
55.8
Socio-demographic characteristics
Gender
Female
76
51.7
0.313
1.00
(ref)
--Male
1997
55.9
1.19
(0.85 - 1.65)
--Age
11-17 years
54
62.8
<0.001
2.48
(1.47 - 4.18)
2.12 (1.19 - 3.79)
18-29 years
1546
58.3
2.06
(1.52 - 2.77)
1.74 (1.23 - 2.46)
30-39 years
396
50.0
1.47
(1.06 - 2.02)
1.26 (0.89 - 1.77)
≥ 40 years
77
40.5
1.00
(ref)
1.00
(ref)
Living situation
Alone
69
50.7
0.544
1.00
(ref)
--With family
1973
55.9
1.23
(0.88 - 1.74)
--With friends
7
43.8
0.76
(0.27 - 2.14)
--Charity
16
59.3
1.41
(0.61 - 3.27)
--Homeless
8
66.7
1.94
(0.56 - 6.75)
--Employment
Regular job
503
50.1
<0.001
1.00
(ref)
1.00
(ref)
Temporal employee
85
66.9
2.02
(1.37 - 2.98)
1.63 (1.10 - 2.43)
Unemployed
1439
57.5
1.35
(1.16 - 1.56)
1.22 (1.05 - 1.43)
Unknown
46
56.1
1.28
(0.81 - 2.01)
1.57 (0.97 - 2.55)
Education
No formal schooling
69
75.0
<0.001
5.30
(3.04 - 9.26)
3.82 (2.16 - 6.76)
1-5 years
653
58.8
2.52
(1.83 - 3.47)
2.01 (1.44 - 2.81)
50
6-8 years
842
9-12 years
440
> 12 years
69
Region
Marmara
629
Aegean
45
Mediterranean
1294
Central Anatolia
74
Southeast Anatolia
3
Black Sea Region
4
East Anatolia
24
Location of treatment
Private clinic
46
Public treatment center (AMATEM)
2027
Drug use behaviors
Heroin as drug of choice
No
10
Yes
2063
Duration of drug use
≤ 2 years
208
3-5 years
664
6-9 years
652
≥ 10 years
549
Used multiple drug types in past month
No
1341
Yes
732
Treatment history
Previous drug treatment
No
767
Yes
1306
a
Restricted to those with known infection status
57.4
51.4
36.1
2.38
1.87
1.00
(1.74 - 3.25)
(1.35 - 2.59)
(ref)
1.93
1.59
1.00
(1.39 - 2.68)
(1.13 - 2.23)
(ref)
53.2
28.9
60.7
41.1
100.0
25.0
48.0
<0.001
1.00
0.36
1.36
0.61
n/a
0.29
0.81
(ref)
(0.25 - 0.51)
(1.18 - 1.57)
(0.45 - 0.84)
n/a
(0.09 - 0.92)
(0.46 - 1.43)
1.00
0.36
1.14
0.58
n/a
0.43
0.79
(ref)
(0.25 - 0.53)
(0.97 - 1.34)
(0.42 - 0.81)
n/a
(0.13 - 1.44)
(0.44 - 1.41)
42.6
56.2
0.005
1.00
1.73
(ref)
(1.17 - 2.54)
1.00
1.60
(ref)
(1.05 - 2.44)
13.7
56.6
<0.001
1.00
8.21
(ref)
(4.20 - 16.05)
1.00
4.83
(ref)
(2.42 - 9.64)
53.3
54.6
59.3
54.3
0.046
1.00
1.05
1.27
1.04
(ref)
(0.84 - 1.32)
(1.01 - 1.61)
(0.82 - 1.31)
1.00
0.99
1.21
1.18
(ref)
(0.78 - 1.26)
(0.94 - 1.55)
(0.90 - 1.55)
54.3
58.6
0.014
1.00
1.19
(ref)
(1.04 - 1.36)
1.00
1.01
(ref)
(0.86 - 1.18)
55.9
55.7
0.859
1.00
0.99
(ref)
(0.86 - 1.13)
---
---
51
TABLE 7
Correlates of HCV infection among current injection drug users receiving inpatient drug treatment in Turkey (n = 3,718)a
HCV-positive
Total
Socio-demographic characteristics
Gender
Female
Male
Age
11-17 years
18-29 years
30-39 years
≥ 40 years
Living situation
Alone
With family
With friends
Charity
Homeless
Employment
Regular job
Temporal employee
Unemployed
Unknown
Education
No formal schooling
1-5 years
6-8 years
Unadjusted
OR
(95% CI)
Adjusted
OR
(95% CI)
n
1930
% HCV+
51.9
p-value
56
1874
38.1
52.5
<0.001
1.00
1.79
(ref)
(1.28 - 2.52)
1.00
1.09
(ref)
(0.75 - 1.59)
30
1325
452
123
34.9
50.0
57.1
64.7
<0.001
1.00
1.87
2.48
3.43
(ref)
(1.19 - 2.93)
(1.56 - 3.95)
(2.01 - 5.85)
1.00
1.21
1.48
2.48
(ref)
(0.73 - 2.01)
(0.87 - 2.54)
(1.32 - 4.65)
84
1825
2
11
8
61.8
51.7
12.5
40.7
66.7
0.001
1.00
0.66
0.09
0.43
1.24
(ref)
(0.47 - 0.94)
(0.02 - 0.41)
(0.18 - 0.99)
(0.36 - 4.32)
1.00
0.72
0.18
0.77
1.19
(ref)
(0.48 - 1.08)
(0.04 - 0.88)
(0.28 - 2.18)
(0.30 - 4.66)
498
69
1333
30
49.6
54.3
53.2
36.6
0.007
1.00
1.21
1.16
0.59
(ref)
(0.84 - 1.75)
(1.00 - 1.34)
(0.37 - 0.94)
1.00
0.77
1.04
0.76
(ref)
(0.51 - 1.14)
(0.88 - 1.22)
(0.43 - 1.35)
56
644
733
60.9
58.0
49.9
<0.001
2.07
1.83
1.33
(1.25 - 3.43)
(1.34 - 2.50)
(0.98 - 1.80)
1.24
1.33
1.27
(0.72 - 2.16)
(0.94 - 1.87)
(0.91 - 1.78)
52
9-12 years
> 12 years
Region
Marmara
Aegean
Mediterranean
Central Anatolia
Southeast Anatolia
Black Sea Region
East Anatolia
Location of treatment
Private clinic
Public treatment center (AMATEM)
Drug use behaviors
Heroin as drug of choice
No
Yes
Duration of drug use
≤ 2 years
3-5 years
6-9 years
≥ 10 years
Used multiple drug types in past month
No
Yes
Shared needles in past 30 days
No
Yes
Treatment history
Previous drug treatment
No
415
82
48.5
42.9
1.25
1.00
(0.91 - 1.72)
(ref)
1.34
1.00
(0.95 - 1.90)
(ref)
437
55
1357
56
3
6
16
37.0
35.3
63.7
31.1
100.0
37.5
32.0
<0.001
1.00
0.93
2.99
0.77
n/a
1.02
0.80
(ref)
(0.66 - 1.32)
(2.58 - 3.46)
(0.55 - 1.08)
n/a
(0.37 - 2.83)
(0.44 - 1.47)
1.00
1.05
3.21
0.84
n/a
1.33
0.61
(ref)
(0.72 - 1.55)
(2.72 - 3.79)
(0.59 - 1.20)
n/a
(0.41 - 4.26)
(0.32 - 1.15)
54
1876
50.0
52.0
0.687
1.00
1.08
(ref)
(0.74 - 1.59)
---
---
15
1915
20.6
52.5
<0.001
1.00
4.28
(ref)
(2.42 - 7.58)
1.00
2.35
(ref)
(1.27 - 4.36)
129
569
598
634
33.1
46.8
54.4
62.7
<0.001
1.00
1.78
2.41
3.39
(ref)
(1.40 - 2.26)
(1.89 - 3.07)
(2.65 - 4.34)
1.00
1.49
1.70
2.26
(ref)
(1.15 - 1.93)
(1.30 - 2.23)
(1.67 - 3.05)
1231
699
49.9
55.9
<0.001
1.00
1.28
(ref)
(1.11 - 1.46)
1.00
0.77
(ref)
(0.65 - 0.92)
691
1239
42.0
59.8
<0.001
1.00
2.05
(ref)
(1.80 - 2.34)
1.00
1.99
(ref)
(1.72 - 2.30)
556
40.6
<0.001
1.00
(ref)
1.00
(ref)
53
Yes
1374
Infection status
HBV-positive
No
1811
Yes
119
HIV-positive
No
1923
Yes
7
a
Restricted to those with known infection status
58.5
2.07
(1.81 - 2.37)
1.97
(1.70 - 2.29)
51.8
54.3
0.459
1.00
1.11
(ref)
(0.84 - 1.46)
---
---
51.9
50.0
0.886
1.00
0.93
(ref)
(0.32 - 2.65)
---
---
54